Inguinal hernia repair and how to recognise the symptoms

There are of two types of inguinal hernia, direct and indirect. For patients this distinction is irrelevant as the same operation fixes both types.

An inguinal hernia is located in the groin region and is the classical hernia that people tend to associate the term "hernia" with. An inguinal herniasb is more common in men than women (but women do get them).

There are of two types of inguinal hernia, direct and indirect. For patients this distinction is irrelevant as the same operation fixes both types.

An inguinal hernia is essentially a weakness in the muscle wall of the abdomen. This weakness allows the lining of the abdominal contents (the peritoneum) to bulge through as a sac.

This peritoneal sac can contain bowel, so usually when you stand up the hernia appears as a lump/bulge in the groin and when you lie down it usually goes away (though sometimes you have to push it in).

Common symptoms include, ache in the groin (often worse as the day progresses), testicular pain is common, trapped wind, and a 'squidding' sensation over the hernia. Frequently patients have no discomfort at all.

There a few techniques for repairing an inguinal hernia, they are:

An inguinal hernia is most commonly repaired using a "tension free mesh repair", this remains the gold standard and has been established practice in most hospitals for many years. The inguinal hernia is repaired by making a small (2 inch) incision in the groin skin crease, a split is made in the external oblique fascia (not the muscle) and the inguinal hernia sac is identified. The sac is then usually tied off and a synthetic mesh is overlaid to strengthen the abdominal wall and prevent recurrence of the hernia.

This method is quick, very reliable, safe and has withstood the test of time. The surgery can be carried out under local or general anaesthetic.

Open repair is the most commonly performed procedure for inguinal hernia surgery and for the majority of hernia patients would be the technique of choice. After over 5 years of laparoscopic repair Mr Sadler reverted back to this technique because he believes when performed under local anaesthetic using it is quicker, more effective, less painful, safer (complications are very rare and less harmful compared to keyhole surgery) and far more cost effective for self paying patients compared with general anaesthetic.

Inguinal hernia surgery is sore (despite some claims to the contrary!). You will be in discomfort for a few days and it will take on average at least a week, possibly longer to be completely comfortable.

The technique we use takes about 30 minutes to perform under local and most patients leave hospital within 30 minutes of surgery. Total length of hospital stay is usually about 2.5 hours based on our last 2000 operations.

No Mesh Technique (Bassini Type) Repair

We can repair your hernia with a "No Mesh Technique", this is called a Bassini Type Repair, after the surgeon who described the technique in 1884. This is remained the standard way of fixing a hernia for over 100 years until the "tension free Mesh technique" became more popular. The technique works very well and many patients who had this type of repair have never had any problems.

However, a 'No Mesh Technique" will not reduce the chance of having chronic discomfort after surgery (it may even increase) and statistically your hernia is more likely to come back, especially if it is a direct hernia. Mr Sadler will discuss this option with you as part of your consent process.

Keyhole Laparoscopic Repair (TAPP)

With a Transabdominal Pre-Peritoneal Repair (TAPP) a telescope is placed into the abdomen via a small umbilical incision and the hernia sac is identified from the inside (Keyhole Surgery).

The hernia sac is pulled back and inverted. The peritoneum (the sac that contains the bowel) is then incised and a large 15 x 15 cm mesh (bigger than that used for open surgery) is placed between the muscle wall and the peritoneum to cover the hernia hole. The peritoneum is then secured back into place with corkscrew like tacks (which themselves can cause problems).

Laparoscopic repair gained popularity a few years ago when it was thought it would be more comfortable post op and quicker to heal, but compared to local anaesthetic open repair there appears to be no significant advantage. There is however potential to damage the bowel, bladder and the major pelvic blood vessels. In inexperienced hands there is more possibility of recurrence of the hernia.

After performing TAPP (and TEP) for many years, Mr Sadler no longer performs any keyhole surgery, favouring local anaesthetic repair (even for bilateral hernias) as he believes it is safer and more comfortable for patients.

Keyhole Endoscopic Repair (TEP)

The Totally Extaperitoneal Repair (TEP), is a minimal access (keyhole) technique. A small incision is made below the umbilicus and a camera is passed into a space behind the abdominal muscles but in front of the peritoneum. The hernia sac is identified and pulled back. A large 15 x 15 cm mesh (bigger than that used for open techniques) is placed over the hernia hole.

The advantage of the technique is that the peritoneum is not entered, making bowel damage slightly less likely than the TAPP operation, bladder damage or damage to the major pelvic blood vessels is still a possibility.

This is a more difficult procedure than the TAPP repair but in experienced hands this is an efficient technique and appears more comfortable than TAPP as the peritoneum is not cut. As with TAPP recurrence rates may be slightly higher than open repair, especially in inexperienced hands.